Hi Tricia,

I'm glad you posted this case, because I would like to hear what others
think about your scenario. And I hope you will find lactnet interesting and
enlightening, as I have over these approx 15 yrs that I've been
participating.

Re your case, the main factor, as I see it, is the premature birth of the 34
wk gestation infant. It doesn't say where you are from (it's helpful and fun
to include your city, state, country at the end of your post), but many
hospitals routinely separate mother/infant in these cases and "allow" far
too little contact, much less skin to skin mothering, and even less direct
breastfeeding or practicing. A 34 wk infant can be relatively very healthy,
or quite sick, so that is certainly a big factor. If at all possible,
parents should have virtually unlimited contact with the infant if well, or
is the baby at home now? In which case, kangaroo mother care should be
ongoing. Another factor is how soon and how regular mother expressed after
the birth, and once the milk surge was felt. Milk stasis will downregulate
production, as you know.

The way I see it, if the "milk comes in" around day 3-5, then basically
mom's anatomy and hormones are in good working order, and she does not need
blood tests etc. Some moms milk comes in "just a little" (they often
describe like that) and a bit of an increased volume is seen for a couple
hours, then soft again. This is not normal, in my opinion. What I expect is
"quite a noticeable increase in the size and firmness of your breasts." When
asked "do you feel that your milk supply has increased or that your milk has
come in?" the mothers invariably answer me "Oh Yeah!" and they do not say "I
think so", or "just a little bit." Even with a robust and gaining weight
baby that is extracting good amounts of milk, this is the answer I expect if
all is going well. Or I can see for myself at the followup visit that the
breasts are quite full and firm. Now back to your case: assess the extent of
her milk surge.

You said you have advised on pumping, massage, so I assume that means
massaging and hand expressing possibly before/during/after electric pump
use. That's good. If she were engorged, the use of RPS is quite an excellent
intervention. There is a little bit to this technique, although quite easy,
and Jean Cotterman has recently updated her info and the use of gravity
(lying on your back) helps even more, so be sure to read that newest
handout; how to get to it found in our archives.

With PCOS, my understanding is that higher androgen (testosterone levels)
are a factor, and insulin resistance, but not necessarily prolactin levels
being a main factor, so I would not think prolactin levels are needed.
Testosterone levels can be done, but not sure what to do about them, so what
is the benefit at this point? Mothers often benefit from taking metformin
and can increase their milk production by making the insulin/glucose system
work better. My understanding is that making the basic sugars work with
insulin (a hormone) to make food (human milk) is what's going on. Obviously,
I am not an endocrinologist, and certainly mother may benefit from seeing
one, and getting all those hormonal things in good working order. So I am
back to the premature birth as the big factor.

To answer your main question: I would *like* mother to be producing 30-60
mls *per breast* per pumping session (8-10x) by the end of a week, to be
feeling really good about her supply. If she is pumping 15 minutes, can she
go longer (25-30 min); she may have more letdowns. I think a good average
would be 20 ounces (600 mls) per day at one week. We have to realize that is
7 days of regular effective expressing since birth. That does not often
occur and that is the problem.

Laurie Wheeler RN MN IBCLC
Mississippi USA

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